The coroner leading an inquiry into the death of a baby girl said there was a 'missed opportunity' to check a patient who was left waiting hours for a doctor review.
Assistant Coroner Elizabeth Didcock is leading the inquiry into Adele O'Sullivan, who died on April 7 2021 after being born without a heartbeat at Nottingham City Hospital.
Mrs O'Sullivan lost her infant son John in 2016 after he developed a condition and died a few days after birth, but his twin sister Anna survived and is now thriving.
Miss Didcock heard evidence from Nottingham University Hospitals (NUH) NHS Trust midwifery staff during the second day of the inquest on Thursday (February 3) at the Council House in Old Market Square.
She raised 'concern' at one point that the midwife overseeing mother Daniela O'Sullivan's care was unsure if a registrar had visited to give pain relief.
Mrs O'Sullivan was treated on Lawrence Ward at City Hospital.
A review into her condition was requested to registrars at around 5.40pm on April 6.
But this did not happen before Mrs O'Sullivan was found to be in pain at around 11pm and was shortly afterwards found to be fully dilated, ready to give birth prematurely at 29 plus one weeks.
The baby's heart rate could not be detected before birth, and Adele died shortly afterwards.
'Two serious complications' were found in the premature baby, according to consultant obstetrician Dr Petra Deering giving evidence on day one of the inquest.
Midwife Leanne Amos, who no longer works at NUH, presided over Mrs O'Sullivan's care during her night shift as one of two midwives caring for patients on Lawrence Ward that night.
During proceedings on day two, Midwife Amos said: "In hindsight, an earlier review would have been appropriate.
"Knowing what I know now, that should have been expedited by me, I would have anticipated other signs."
Miss Didcock interjected, saying: "That review should have been expedited then, even without knowing what we know now.
"That's what should have happened, that's a missed opportunity."
Midwife Amos agreed, continuing: "Between 9.08pm and 11pm on April 6 2021, I don't recall going back to see Mrs O'Sullivan as she wanted to have a shower, so I removed her CTG (cardiotocography, a baby heart rate monitor).
"I was not made aware there were any changes during that time, but when I went to see her at 11.05pm, she looked uncomfortable.
"I do not recall seeing a registrar before 11pm to give Mrs O'Sullivan pain relief."
Miss Didcock said: "It's concerning you did not know the doctor was there, and Daniela's statement says she was in pain before 11pm."
Midwife Amos said: "Daniela needed one-to-one care.
"After going to the labour suite, forceps was used twice, as the baby started to be born with an arm out first, but that caused bleeding each time.
"The registrar was unsure of which method of birth was best."
Mrs O'Sullivan eventually gave birth through a caesarean section under general anaesthetic in the early hours of April 7.
Registered nurse and midwife Deborah Moody was the other midwife caring for patients during this time.
She said there were issues with staffing that night, and with just herself and Midwife Amos caring for 16 patients, they split them so each cared for eight, with one patient each to keep a closer eye on, including Mrs O'Sullivan.
During proceedings, Midwife Moody said: "I saw Daniela at one stage, and she said to me this is like what happened with my first baby.
"I think we were particularly short staffed.
"I think we were just really busy and we're used to being busy and getting on with it.
"When you're so busy, it's hard to get a grip of what's going on from one patient to another and it's hard to get an entire picture of what's going on in the whole unit."
When asked by Miss Didcock what could have been improved, Midwife Moody said: "An earlier doctor review."
The initial request for a review was submitted by midwife Katy Trivell, who was in charge of the ward before the emergency.
During proceedings, Midwife Trivell said: "I could have tried to get hold of the registrar myself, but nothing different was escalated to me by the midwife who was taking care of her through the day shift."
The inquest continues on Friday (February 4) at the Council House.
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